Drug requirements definitions

You may have noticed your drug has abbreviations next to it indicating a restriction or limitation on the amount of a drug you can get. Below is our key, which defines your drug(s) limitations.

Part B vs. Part D (B/D) coverage
You'll pay for some drugs differently depending on whether they are covered by your medical plan (Medicare Part B, you pay 20% coinsurance) or your drug plan (Medicare Part D, you pay your prescription copay). It depends on the use and setting of the drug.

Quantity limits (QL)
Priority Health Medicare limits the amount that we will cover on some drugs. For example, we have a quantity limit of 60 tablets per 30 days for ELIQUIS. This may be in addition to a standard one-month or three-month supply.

Prior authorization (PA)
Priority Health requires you or your physician to get pre-authorized for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don't get approval up front, your Priority Health Medicare Advantage plan may not cover the drug.

Step therapy (ST)
A step therapy requirement means that, in some cases, we may require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

For example, if Drug A and Drug B both treat your medical condition, your plan may not cover Drug B until you first try Drug A. If Drug A does not work for you, Priority Health Medicare will then cover Drug B.

Priority Health has HMO-POS and PPO plans with a Medicare contract. Enrollment in Priority Health Medicare depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments and restrictions may apply. Benefits, formulary, pharmacy network and premium may change on January 1 of each year. You must continue to pay your Medicare Part B premium.